MEDICARE: GORDON REED WOUTERS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	114045	MO

General Provider Information

NPI Number	:	1851402010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON REED WOUTERS DO

Provider Business Mailing Address
First Line	:	1500 N OAKLAND
Second Line	:
City	:	BOLIVAR
State	:	MO
Zip	:	65613
Country	:	US
Telephone Number	:	417-745-2121
Fax Number	:	417-745-6141

Provider Business Practice Location Address
First Line	:	HWY 254 & DALLAS ST.
Second Line	:
City	:	HERMITAGE
State	:	MO
Zip	:	65668
Country	:	US
Telephone Number	:	417-745-2121
Fax Number	:	417-745-6141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	01/04/2010

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Directions to “ GORDON REED WOUTERS DO” Practice Location

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